Commissioning in the Early Years

From next year, councils will take on new responsibilities for commissioning in the early years. This briefing outlines opportunities this transfer brings and the planning work currently being undertaken by NHS England and London Councils ahead of the changes.

Overview

In October 2015, councils will receive a new duty to commission services for children in the early years, specifically health visiting and in some boroughs, Family Nurse Partnerships (FNP). Together, not only will these services bring new investment in local authority early years and public health, but will offer boroughs an exciting opportunity to create a new local vision for integrated commissioning in the early years and across the wider 0 to 19 and whole life pathway. However, learning from previous public health transfers will need to be applied as local government and health put in place the stepping stones which will ensure the resources follow the responsibility for commissioning.

Public health in the early years

The specific commissioning responsibility being transferred to local government includes:

- Health Visiting services as set out under the Healthy Child Programme
- Family Nurse Partnership services.

A map showing local authorities and their current health visiting providers is attached as appendix 1.

While highly regarded, not all local authorities have a FNP in place. FNP was created in local authority areas on a needs-led basis in order to support first-time teenage mothers; broadly speaking, the first wave of FNP was focused on the most deprived areas and latter waves followed deprivation levels. The government has expanded FNP nationally since 2010, but only those approved now will transfer to local government. In instances where a FNP service is not in place, parents and children usually captured by FNP criteria will be supported through universal health visiting and other tiers of the health visiting service.

After midwives, health visiting services are often the first professionals to have contact with new-born children and their parents and provide a vital bridge to other local early years services. Health Visitors are trusted and welcome contributors to the lives of most parents and have a valuable opportunity to work with children and parents and carers to give children the best start in life. Health visitors are also vital to the early identification of children or parents needing extra support to develop and thrive. Outcomes data provides a helpful context to why health visiting and FNP are central to steps to improve the lives of London’s children:

- about 3 in 100 babies born at term in London have a low birth weight
- at least 1 in 10 women (about 13,400 new mothers in London) will suffer from a perinatal mental illness
- the perinatal mortality rate for 2009-11 for London (7.9 per 1,000) was higher than the average for England (7.5 per 1,000)
- in 2012, 519 babies did not live to see their first birthday
- about 9 in 10 mothers in London breastfed their baby at birth
- 1 in 10 children living in London did not receive their third dose of immunisation at 12 months
- tooth decay is the most common chronic disease in childhood and in many parts of London is the most common cause of non-emergency admissions among children
- 1 in 4 children is overweight or obese when they start school.

The financial context of children’s health gives a different accent to the case for creating strong health visiting services within an integrated early years pathway:

- the cost of smoking in pregnancy in London contributing to preterm births is estimated to be £24 million - £38 million
- in the first five years of life, each birth to a teenage parent costs the public sector £57,900 - this is about £53 million in London
- targeted parenting programmes to prevent conduct disorders pay back £8 over six years for every £1 invested
- a child’s early development score at 22 months is an accurate predictor of educational outcomes at age 26 years.
- an obese child in London is likely to cost around £31 a year in direct costs, which could rise to a total (direct and indirect) of £611 a year if they continue to be obese into adulthood
- health visitors identifying and treating postnatal depression improves productivity and leads to cost savings in the medium to short term
- the impacts of childhood psychiatric disorders cost London’s education system approximately £200 million per year.

The outcomes and financial context make a compelling case both for strong universal health visiting and for health visiting and FNP services as a central component to integrated early intervention and prevention strategies. A child’s experience in the early years is a significant factor in long term outcomes. Helping all children to have the best start in life can lead to reductions in the need for high-cost statutory provision across the whole-life pathway.

**Health Visiting**

The National Health Visiting Service Specification includes the following four key elements:

- Community: health visitors have a broad knowledge of community needs and resources available and work to develop these and make sure families know about them.

- Universal: health visiting teams lead delivery of the Healthy Child Programme, ensuring that every new mother and child have access to a health visitor, receive development checks and receive good information about healthy start issues such as parenting and immunisation.

- Universal Plus: families can access timely, expert advice from a health visitor when they need it on specific issues such as postnatal depression, weaning or sleepless children.

- Universal Partnership Plus: health visitors provide on-going support, playing a key role in bringing together relevant local services, to help families with continuing complex needs for example where a child has a long term condition. As part of the transfer to local government, the Department of Health is taking steps to regulate for the following universal health visiting checks to be mandated:

- antenatal health promotion review

- new baby review, which is the first check after the birth

- 6-8 week assessment

- 1 year assessment

- 2 to 2 and a half year review.

**Family Nurse Partnerships**

Although there is a great deal of overlap in the types of support provided to children and parents, FNP is distinct from health visiting services.

FNP is an evidenced based, preventive programme offered to young mothers aged 19 years and younger having their first baby. It begins in early pregnancy and is orientated to the future health and well-being of the child. It is a nurse-led intensive home visiting programme, rigorous enough to make a difference and filling the needs gap in the continuum of the Universal Healthy Child Programme where intervention at the Universal Plus level and perhaps beyond is required.

The evaluation of first ten pilot sites carried out the University of showed that mothers participating in the Family Nurse Partnership:

- stopped smoking in pregnancy or smoked fewer cigarettes
- initiated breast-feeding at a high rate
- coped better with pregnancy, labour and parenthood
- had increased confidence and aspirations for the future
- were returning to education and taking up paid employment
- were very positive about their parenting capacity and reported high levels of warm parenting.

Independent studies show that delivering the Family Nurse Partnership programme results in significant financial benefits to participants, the public purse and wider society. Economic benefits increase over time as the children get older but there are indications that the cost of the programme is recovered by the time the children are aged four for the highest risk families and certainly by age 12.

**Transfer Planning**

London Councils and NHS England (London) have jointly appointed a Programme Manager to support London’s transfer planning. The Programme Manager is Clive Grimshaw and may be contacted on clive.grimshaw@londoncouncils.gov.uk or 020 7934 9830.

The priority of the London transfer programme during the summer of 2014 has been to facilitate the process of transfer planning dialogue. The process of dialogue between NHS England (London) and local government will be an iterative one. There will be a range of issues which local government will wish to understand, consider and respond to in advance of the local government draft baseline budgets being shared in October and financial allocations being announced in December. It is unlikely that all of those issues will be resolved immediately but it is important that there is a joint health and local government process for providing a smooth and effective transition. Therefore, the expectation is that dialogue will be ongoing and will be tailored to borough needs where possible. The next step will be for local government to receive a draft baseline budget from the Department of Health by the end of October. Commentary

As with previous transfers and any creation of a new duty, there are risks and opportunities to be factored in and considered.

With regard to the risks, each borough will be need to fully consider the financial, legal and performance issues. These will vary by borough, but commonly boroughs will wish to be mindful of:

- Are expectations of councils as the future commissioner realistic in the context of current delivery of the checks which will be mandated?
- Is the financial envelope identified to transfer to local government sufficient to commission a service which meets the Government’s requirements as set out in mandation?
- Has the process of identifying the financial and workforce scope been conducted transparently?

The opportunities are significant as the evidence in this briefing illustrate. The early years of a child’s life are formative ones emotionally, socially, physically and cognitively. Evidence from research shows that supporting children to develop and thrive in those early years can pay significant dividends later in life. Where children do not benefit from an environment where they are supported to develop and thrive, the impact can be long lasting, damaging and costly. Local government has been at the centre of developing models of early intervention over a number of years; the transfer of these commissioning responsibilities therefore create the opportunity to strengthen and deepen local early intervention and prevention as the health visiting service will often be the first line of contact for new parents and carers and their children.

The opportunity to strengthen and deepen the provision of local universal and targeted support in the early years resonates strongly with public service reform in other areas, such as Troubled Families, where the case for long term cost benefit is driving a reorientation towards early intervention and prevention. A London Councils briefing on the Troubled Families programme is available here.

Furthermore, as the pressure of public sector austerity continues to be felt by boroughs, and with a Comprehensive Spending Review in 2015 expected to deliver further cuts to councils’ spending power, there will be more need to develop and support service models which divert and prevent pressure on high-cost, specialist and targeted interventions. The imperative therefore will be on maximising the opportunity of closer integration of universal health visiting and FNP with the wider health and care pathway to ensure children are supported to develop and thrive through the early years and achieve a smooth and successful transition into later stages in life.

Author: Clive Grimshaw, Programme Manager (020 7934 9830) Click here to send a comment or query to the author

Links: London Councils Member briefing on Troubled Families

This member briefing has been circulated to: Portfolio holders and those members who requested policy briefings in the following categories: Children and Young People; Health and Social Care